Provider Demographics
NPI:1124756440
Name:MCKENNA, AMANDA RAU
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:RAU
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SEABREEZE RD
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2723
Mailing Address - Country:US
Mailing Address - Phone:860-209-6165
Mailing Address - Fax:
Practice Address - Street 1:5 SEABREEZE RD
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2723
Practice Address - Country:US
Practice Address - Phone:860-209-6165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-14
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005571101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty